June 8–11, 2018
San Diego, California
More than 225 participants from 46 nations attended the 23rd Annual National Institute on Drug Abuse (NIDA) International Forum, held June 8–11, 2018, in San Diego, California. International Program Director Steven W. Gust, Ph.D., chaired the meeting. A joint NIDA International Forum/College on Problems of Drug Dependence (CPDD) poster session featured presentations on international research conducted by 131 scientists from the United States and 34 other countries. Plenary sessions addressed the partnership between NIDA and CPDD, estimating the harms and the economic burden of substance use in Canada, adulteration of drugs with toxic cutting agents, opioid overdose prevention, kratom use, international Addiction Technology Transfer Centers, and the International Consortium of Universities for Drug Demand Reduction (ICUDDR). Workshops focused on evidence-based demand reduction, animal-assisted interventions for addiction treatment and prevention, preparing international research for publication, and the impact of the Hubert H. Humphrey Drug Abuse Research Fellowships on global drug research networks and fellows’ career development. CPDD International Committee Chair Clyde McCoy, M.D., University of Miami Miller School of Medicine, reviewed the International Committee activities and introduced the 2018 CPDD International Traveling Fellow, Nicolás Poliansky of Argentina, who is collaborating with Hendrée Jones, Ph.D., at the University of North Carolina.
Plenary Sessions
CPDD and the NIDA International Forum: A History of a Successful Partnership
A former CPDD treasurer, Linda Cottler, Ph.D., M.P.H., University of Florida, briefly reviewed the history of the organization, which was created in 1929 and is the longest-standing group in the United States addressing drug dependence and abuse. In 1996, Dr. Cottler was among the 65 participants in the first NIDA International Forum, which included participants from 21 countries and 15 poster presentations. She reviewed the impact of the meeting on academic partnerships, research projects, funding, training opportunities, career development, and publications. Among the key outcomes from the meeting are more than 30 NIDA grants associated with the Forum between 2012 and 2017; binational research on naltrexone to treat opioid use disorder, which led to U.S. Food and Drug Administration (FDA) approval of Vivitrol; World Health Organization (WHO) guidelines for treating substance use in pregnant women; the International Programme in Addiction Studies online master’s degree program; creation of the Latin American epidemiology network, Red Latinoamericana de Investigaciones en Drogas, the International Women’s and Children’s Health and Gender Group, and numerous international research teams; coordination of international research on drug-related HIV infection; dissemination of evidence-based interventions; creation of international drug abuse research centers; career development and training opportunities; and research publications in peer-reviewed journals. Dr. Cottler also discussed how the Forum and NIDA International Program address the WHO principles for strengthening research capacity and outlined challenges for the drug abuse research community, such as changes in policy, designer drugs, health consequences of marijuana use, alternatives to opioids for pain management, the impact of tobacco use in low- and middle-income countries, and continued capacity building.
Estimating the Harms and the Economic Burden of Substance Use in Canada
Canadian Centre on Substance Use and Addiction (CCSA) Senior Research & Policy Analyst Matthew M. Young, Ph.D., reported on a CCSA project to assess how use of alcohol, tobacco, cannabis, cocaine, opioids, central nervous system depressants and stimulants, and other psychoactive substances affected Canada between 2007 and 2014. Dr. Young and colleagues used attributable fraction methodology to assess costs of substance use on health care, productivity, criminal justice, and other costs such as prevention interventions, research, worker’s compensation, workplace drug testing, motor vehicle damage, fire, and administrative expenses. The researchers found that in 2014, substance use was responsible for more than 255,000 hospitalizations, 67,000 deaths, and 751,000 potential years of life lost due to premature mortality. More than 70% of these costs were attributable to use of the legal substances alcohol and tobacco. Alcohol was the most expensive substance, responsible for 38% of all 2014 costs. Per capita costs increased 11.6% between 2007 and 2014. Being under the influence of or seeking alcohol was also responsible for 20% of violent crimes. Opioid use was the third-highest cause of harm and economic costs, primarily due to early deaths, but accounted for only 9.1% of total costs in 2014. Dr. Young noted that opioid-related deaths have been increasing among younger Canadian populations since 2014, and predicted that opioid-attributable costs of disability and mortality will continue to increase. The largest per capita increase between 2007 and 2014 was associated with cannabis, at 19.1%; however, the per capita costs of cannabis use are just 25% of the per capita costs of alcohol. Most cannabis crime costs are due to its status as an illegal substance between 2007 and 2014, which may change as new Canadian laws legalize personal use.
Adulteration of Drugs With Toxic Cutting Agents: A Rapidly Developing Global Public Health Emergency
In 2010, Brazilian treatment centers asked U.S. officials for help in finding the cause of unusual infections, diseases, and other health problems among clients who used cocaine. Thom Browne, Jr., Rubicon Global Enterprises, reported on the ongoing, global investigations into cutting agents added to illicit drugs. Using samples from drug seizures in Africa, Asia, Europe, and North and South America, investigators have identified multiple, highly toxic additives that resulted in synergistic pharmacological impacts and adverse side effects. Adulterants have been found in heroin, cocaine, methamphetamine, and other drugs. Evidence suggests that adulterants are added in source, transit, and consumer countries; historically, adulterants were added only in the consumer country. In some samples of heroin or cocaine, the purported drug is often the smallest ingredient among up to 10 adulterants. Naloxone is less effective in treating heroin overdose when adulterants are present in the illicit drug and is not effective for other classes of drugs such as benzodiazepines. Few treatment centers test their clients for the presence of adulterants.
These adulterants include banned pharmaceuticals (levamisole, phenacetin), veterinary products (ketamine), designer drugs (cathinones, MDMA, and 2C-B, a synthetic analog of mescaline), anesthetics (procaine), pain relievers (lidocaine, benzocaine, metamizole, aminopyrine, and acetaminophen), antipsychotics (quetiapine), antimalarials (quinine), antihistamines (diphenhydramine), opioid pain medications (fentanyl, tramadol), muscle relaxants (xylazine and carisoprodol), antihypertensives (diltiazem), industrial solvents (diethylene glycon dibenzoate), nerve agents (diethyl methylphosphonate), fungicides (maneb and chinomethionate), stimulants (caffeine), and impurities from the heroin manufacturing process. Adverse effects consist of decreased production of red and white blood cells due to bone marrow damage, multifocal inflammatory leukoencephalopathy, hemolytic uremic syndrome, renal failure, multiple malignancies, cardiac arrhythmias, convulsions, low blood pressure, central nervous system depression, neurodegeneration, respiratory distress, opportunistic infections, idiopathic pulmonary hypertension, and death.
In 2015, the U.S. Department of State Bureau of International Narcotics and Law Enforcement Affairs began working with the Colombo Plan to test for adulterants globally. The project has developed an instant urine test kit for phenacetin, and is working on test kits to identify levamisole and aminopyrine. Once the test kits are validated, the partners will seek FDA approval.
Mr. Browne recommended that adulterant testing become a part of standard drug toxicology panels used by public health departments, health care providers, emergency departments, medical examiners, crime laboratories, and substance abuse treatment centers, so that public health alerts may be issued when needed. He also called for research to better understand the patterns of adulterant use and their potential contribution to morbidity and mortality, and for development of a comprehensive health risk assessment tool that identifies the interactive effects of multiple controlled drugs, toxic adulterants, and heroin impurities to better guide clinical and medical practice.
International Perspectives on Opioid Overdose Prevention: Challenges and Innovations
Opioid overdose is a growing public health epidemic around the world. NIDA Center for the Clinical Trials Network (CTN) Director Betty Tai chaired this session, which reviewed epidemiological data, strategies to address opioid overdose, and opioid overdose prevention programs in Asia, Australia, and the United States. Elizabeth Sáenz, M.D., M.P.H., M.M.C.H., United Nations Office on Drugs and Crime (UNODC), introduced the UNODC/WHO Stop Overdose Safely program to create protective environments and support community management of opioid overdose. The 2018–2020 study will evaluate the feasibility of increasing access to naloxone, effectiveness of training lay people in overdose management, and impact of the program on overdose deaths. The goal is to use science and policy in prevention, treatment, and care of drug use disorders and promote options for treatment and care as alternatives to conviction or punishment. Work is underway in Kazakhstan, Kyrgyzstan, Tajikistan, and Ukraine; other countries may join if they have resources to conduct the research. Robert Ali, M.B.B.S., D.P.H., FAFPHM, FAChAM, reviewed Australia’s introduction of take-home naloxone opioid overdose programs in Australia. He described the decade-long, complicated process of implementing the program, discussing the multiple government and community organizations involved as well as remaining barriers to access and affordability. Dr. Ali added that the emergence of high-potency opioids represents an additional factor in increasing rates of opioid overdose. Chitlada Areesantichai, Ph.D., summarized statistics on overdose, overdose death, and prevention efforts in 13 Asian nations. She also reported on results of harm reduction interventions among people who inject drugs in Thailand that prompted Thai officials to expand overdose prevention interventions and provide naloxone beginning in 2017. Manchester, New Hampshire, Fire Chief Daniel Goonan described his city’s Safe Station program to provide free, face-to-face, and immediate access to substance use disorder or mental health treatment 24/7 at any of the city’s 10 fire stations. The program reduces both stigma and delays in accessing treatment. In 2 years, firefighters have referred more than 4,000 individuals to community treatment providers, and overdose deaths dropped 24% between 2016 and 2017 even though the number of overdoses increased by 11%. The NIDA CTN is supporting an assessment of the program to identify the key ingredients for implementation and sustainability. Challenges include funding and lack of resources such as treatment and recovery services, transitional housing, and quality sober living homes.
International Consortium of Universities for Drug Demand Reduction (ICUDDR)
ICUDDR supports improvement in competencies and skills among current and future generations of addiction professionals to meet the increasing demand for a multidisciplinary workforce equipped to deliver new and enhanced prevention and treatment services. Michal Miovsky, Ph.D., Czech Republic, reported on university surveys in Europe and North America that identified key characteristics of university programs in addiction studies. He described ICUDDR’s role in developing a network of universities that are creating addiction studies programs; establishing education and career development programs for addictions professionals; advancing applied research; facilitating partnerships between academic programs, addiction professionals, and researchers; and advocating for university support of addiction studies. Roger Peters, Ph.D., University of South Florida, described the role of ICUDDR coordinating centers in helping universities access universal curricula for addiction prevention and treatment and adopt international credentialing programs available through the International Society of Substance Use Prevention and Treatment Professionals (ISSUP). ICUDDR Executive Director Kim Johnson, Ph.D., described the organization’s role in developing feedback loops between research, education, and practice. Igor Koutsenok, M.D., University of California San Diego, reported on the need for addiction medicine training in medical schools to counteract deficits in knowledge and clinical skills as well as negative attitudes among health care professionals. He noted that brief, skills-based curricula that combine interactive, experiential, and didactic elements improve physician knowledge, attitudes, and practices, particularly in primary care settings.
Identifying Knowledge Gaps as Kratom Emerges on the Global Stage
Kratom has been reported to relieve pain, alleviate opioid withdrawal, and ease symptoms of depression. Researchers from University Sains Malaysia have conducted some of the most detailed research on kratom pharmacology, neurobiology, and human field studies. Sharif Mahsufi Mansor, Ph.D., described the pharmacology of kratom, concluding that the substance is chemically unrelated to any known analgesic agents or opioid medications. He added that kratom activity and side effects are qualitatively different from narcotic analgesics, and called for controlled clinical trials to evaluate kratom as an analgesic or potential opioid treatment medication. Surash Ramanathan, Ph.D., discussed additional preclinical pharmacological studies of kratom. The drug has very low bioavailability and long elimination half-life, and is safe at doses lower than 10 mg/kg but toxic to rats at 100 mg/kg. He reported that there is little evidence about death related to kratom poisoning. Zurina Hassan, Ph.D., reviewed the neurobiology of kratom, including abuse liability, affected neurocircuits, and cognitive effects. She noted that higher doses led to conditioned place preference and locomotor sensitivity, indicating that kratom may have addictive properties. Drug discrimination tests, however, suggested pharmacological similarities between morphine and kratom and that the subjective effects and abuse potential of kratom are relatively lower compared with morphine. Thus, Dr. Hassan recommended evaluating kratom as a potential treatment for opioid use disorder. She reported that high doses of kratom impaired memory in new learning tasks during abstinence. Both the opioidergic and GABAergic systems were involved in conditioned place preference and memory and learning functions. Darshan Singh, Ph.D., described human field studies of kratom that employed in-depth interviews, focus group discussions, structured surveys, and standardized assessment instruments. He reported on studies with conflicting results suggesting that regular kratom users may become dependent and experience dose-dependent withdrawal symptoms. Dr. Singh recommended that controlled clinical trials are needed to establish the long-term safety and toxicity of kratom use. Marek Chawarski, Ph.D., Yale School of Medicine, reviewed the key findings presented during the session and outlined future research planned by the binational research team, which hopes to establish evidence for evaluating the potential therapeutic use of kratom and better understand its safety and toxicity. Future investigations include clinical and preclinical studies of the effects of kratom on pain; clinical studies of the effect of kratom on opioid withdrawal symptoms and dependence; and pharmacological, pharmacodynamic, and pharmacokinetic studies of the active compounds in kratom.
Addiction Technology Transfer Centers in South Africa, Southeast Asia, Ukraine, and Vietnam: Models for Future Engagement
The Substance Abuse and Mental Health Services Administration and the President’s Emergency Plan for AIDS Relief have recently established Addiction Technology Transfer Centers (ATTC) in Southeast Asia and Vietnam, South Africa, and Ukraine. Anna Blyum, M.S., the project coordinator for the Ukraine ATTC, described the diffusion and dissemination of information theory that shapes the ATTC mission of accelerating the implementation of evidence-based treatment for substance use disorder. ATTC partners receive assistance in conducting a needs assessment, support to train a professional workforce, and intensive technical support to implement innovations. David J. Grelotti, M.D., University of California San Diego, described how the ATTC works at multiple levels to provide tools and expertise to address comorbid HIV and substance use disorders in Ukraine. He cited the creation of measurable outcomes to demonstrate the value of addressing substance use disorders in responding to the HIV epidemic. The ATTC team in Ukraine identified structural reforms to alleviate harmful social conditions; promoted resilience to counteract early life adversity; treated the intertwined epidemics of depression, substance use, childhood sexual abuse, exposure to violence, and risky sexual behaviors; developed targeted prevention interventions to address HIV vulnerabilities such as injecting drugs; and integrated services to treat people living with HIV. Opioid agonist therapy reduced syndemic factors such as injection drug use, sexual risk, depression, and exposure to violence while improving participants’ quality of life, relationships with health care providers, and engagement in care for HIV, reproductive health, and other medical comorbidities. Sherry Larkins, Ph.D., University of California Los Angeles, described the ATTC accomplishments in training and accrediting health care providers in medication-assisted therapy to address the drug abuse-related HIV epidemic in Vietnam and Thailand as well as Burma (Myanmar), Cambodia, Indonesia, and Laos. The project also expanded university programs in addiction medicine, implementing case-based learning, clinical supervision, and case review protocols. The ATTC team consulted with governments reviewing policies and programming, and cooperated with regional partners such as the Colombo Plan, UNODC, and WHO to develop, translate, and adapt resources and pilot programs. Goodman Sibeko, M.D., Ph.D., who is a co-director of the South Africa HIV ATTC, described how South Africa accounts for 19% of all HIV infections, 15% of new HIV infections, and 11% of HIV-related deaths worldwide. Alcohol use is a primary factor in HIV transmission in South Africa. The ATTC team is conducting needs assessments, engaging with governmental and nongovernmental stakeholders, creating a national strategic advisory board, and developing training programs in screening, brief intervention, and referral to treatment; motivational interviewing; basic counseling skills; and mental health training for lay workers, family physicians, and review boards. Dr. Koutsenok, who directs the Ukraine ATTC project, described the project’s objectives for addressing the HIV epidemic, including assisting in the development of a National Center of Addictive Disorders; developing procedures for certification, licensing, and accreditation of treatment providers; and advising the government on issues related to HIV, substance use disorders, mental health services, and the general health care system. Training will focus on medication-assisted therapy, screening and brief interventions, psychosocial interventions, relapse prevention, and services for people in prison or other high-risk environments.
Workshops
Evidence-Based Demand Reduction: Role in Policy and Programs
This workshop focused on ways to promote adoption of evidence-based drug abuse education, interventions, and policies through best practices, fellowships, and U.S. government programs. Thomas Babor, Ph.D., M.P.H., University of Connecticut, summarized the findings presented in Drug Policy and the Public Good, which analyzes scientific evidence to inform drug policy at the local, national, and international levels. The book authors identified four system changes that made a difference in substance use: (1) introduction of large-scale opiate substitution services in France and Switzerland; (2) creation of the drug court system in the United States; (3) promotion of clinical practice guidelines for opiate substitution in the United Kingdom; and (4) the example of alcohol treatment and Alcoholics Anonymous. Dr. Babor reported that findings from more than 1,000 research articles, literature reviews, scholarly books, and government reports demonstrate that an integrated and balanced approach to evidence-informed drug policy is more likely to benefit the public good than are uncoordinated efforts to reduce drug supply and demand. He warned that political actions in the arena of drug policy are often driven by symbolism and political agendas rather than by evidence on practical effects, and that policymakers will have to make a greater investment in policy science and analysis if they want to benefit society by adopting a more scientific approach to drug policy.
William J. McGlynn and Andrew B. Thompson, Ph.D., discussed global demand reduction programs supported by the U.S. Department of State Bureau of International Narcotics & Law Enforcement Affairs (INL). They noted that drug prevention and treatment are key components of U.S. international counterdrug policy. INL works with more than 90 countries, other U.S. agencies, and international partners to help develop the global drug demand reduction workforce, professionalize treatment and prevention services, build global networks and community coalitions, and address populations with special needs. INL has worked with the scientific research community and international organizations such as the Colombo Plan and UNODC to map global treatment capacity and develop evidence-based training and accreditation programs. Key elements are the Universal Treatment Curricula, Universal Prevention Curricula, and specialized training programs for treatment of women, children, and people in rural communities. To expand access to these programs, INL also helps support ISSUP, which is a membership organization that allows practitioners and experts to share scientific information and best practices, and ICUDDR to promote university programs in addiction studies. Outcome evaluation studies have documented the impact of workforce training programs in several countries. Brazil and Peru reported significant reductions in drug availability, with a 32% reduction in drug dealing among high-risk juveniles in Sao Paulo, Brazil, and a 25% reduction in drug sales in Peru. Countries reporting significant public health impacts included Afghanistan, with a 64% decrease in suicide attempts among women; Thailand, with a 66% reduction in HIV high-risk behaviors and an 80% reduction in overdoses; and Vietnam, with an 85% reduction in intravenous heroin use.
Hubert H. Humphrey Fellowship Updates
The U.S. Department of State Hubert H. Humphrey Fellowship Program is celebrating its 40th Anniversary. Anthony Koliha, M.A., Director of the Office of Global Educational Programs at the U.S. Department of State, described how the exchanges benefit both the United States and the fellows’ home countries by providing a global perspective and the opportunity to share best practices and learn from national similarities and differences. Mr. Koliha noted that the Hubert H. Humphrey Fellowships in substance abuse education, treatment, and prevention are the only science-based fellowships among the 16 program fields, and a unique opportunity for the State Department to partner with NIDA on a topic that has a profound impact on society’s health. He encouraged alumni to recruit new applicants and maintain contact with the U.S. Embassies in their home countries. NIDA has supported Humphrey Fellows in substance abuse research since 1990, and since 2005, Virginia Commonwealth University (VCU) has hosted 108 NIDA Hubert H. Humphrey Drug Abuse Research Fellows from 52 countries. J. Randy Koch, Ph.D., director of the Humphrey Fellowship Program at VCU, and Olena Leonchuk, Ph.D., North Carolina State University, reported on their quantitative and qualitative assessment of the VCU Humphrey Fellowships. Former VCU Humphrey Fellows are asked about their demographics, employment, professional development, and satisfaction with the fellowships with 1-, 3-, and 5-year follow up surveys. The response rate was 92.8%. Of the 77 respondents, 70.8% agreed that the Humphrey Fellowship helped them get a new job, and 91.3% said that during their fellowships, they had learned about an evidence-based practice or program that would be useful to implement in their home country. Nearly 68% had attempted to implement a project that they had developed during their fellowship, and 34.7% had collaborated with a U.S. colleague. Almost all (96.8%) of the former Humphrey Fellows were satisfied with their fellowship experience, and 97.1% had encouraged friends and colleagues to apply for a Humphrey Fellowship. In addition, stratified random sampling identified the 10 former fellows who took part in qualitative interviews 1 and 5 years after their fellowships. The interviews provided more details about former fellows’ attempts to implement projects and collaborate, and their views about mentoring, cultural exchanges, and the impact of the fellowship on their careers. All said that the fellowship had had a positive impact on their careers and that they returned home with positive impressions of the United States.
Animal-Assisted Interventions for Addiction Treatment and Prevention
This interactive workshop examined how the human-animal bond, particularly animal-assisted interventions, can help enrich wellness among individuals and communities. Colleen Anne Dell, Ph.D., University of Saskatchewan, discussed her work in Canada with people enrolled in addiction treatment programs, those with co-occurring mental health disorders, and those in criminal justice institutions. Participants shared their experiences and asked questions about initiating animal-assisted interventions.
ISAJE Workshop: Preparing Your Research for Publication
This International Society of Addiction Journal Editors (ISAJE) workshop suggested online training materials and resources to help novice researchers publish in scholarly journals. Richard Saitz, M.D., M.P.H., Boston University School of Public Health, and Adam Gordon, M.D., M.P.H., University of Utah School of Medicine and Salt Lake City VA Health Care System, discussed selecting a journal, preparing manuscripts, making editorial decisions, responding to reviewers, revising and resubmitting, and dealing with issues that arise after acceptance. Participants asked questions about publication practices and ethical issues common in addiction science publishing.